Late cART Initiation Consistently Driven by Late HIV Presentation: A Multicenter Retrospective Cohort Study in Taiwan from 2009 to 2019

Abstract

Introduction Late initiation (LI) of combination antiretroviral therapy (cART)—defined as having a CD4 + count of < 200 cells/μL or an AIDS-defining disease at cART initiation—has detrimental outcomes but remains prevalent worldwide, with LI trends and etiologies following the implementation of various HIV policies remaining underinvestigated. We assessed key concerns, characterized the determinants of various statuses at cART initiation, and evaluated the effects of those statuses on all-cause mortality after cART initiation. Methods This multicenter retrospective cohort study enrolled 1198 patients with newly diagnosed HIV infection during 2009–2019 who were grouped by status at cART initiation: those without LI (non-LI group, 56.01%); those with LI but without late presentation (LP) of HIV (LP: a CD4 + count of < 200 cells/μL at HIV presentation or AIDS events ≤ 3 months of HIV diagnosis) [LILP(−) group, 4.51%]; and those with LI and with LP of HIV [LILP(+) group, 39.48%]. Joinpoint regression was used to identify changes in LI proportion. Results The median CD4 + count at cART initiation increased significantly between 2009 (98 cells/μL) and 2015 (325 cells/μL) and stabilized thereafter ( P for trend < 0.001). For LI, we identified one joinpoint in 2015: a substantial decrease from 77.14% in 2009 to 34.45% in 2015, followed by a nonsignificant increase to 39.1% in 2019. Overall, LILP(+) explained 89.8% of LI, without significant changes (92.59% in 2009 to 94.23% in 2019). In addition to HIV diagnosis during 2009–2012, multinomial logistic regression identified an age over 30 years and acute HIV infection as risk factors for LILP(+) and LILP(−), respectively. LILP(−) and LILP(+) were associated with a higher all-cause mortality risk. Conclusion Given the rise in LI from 2015 in the era of treat-all and rapid cART initiation, strategic interventions to increase earlier cART initiation must be intensified in Taiwan, especially among populations with delayed access to HIV testing services.

Sex stratification of the trends and risk of mortality among individuals living with HIV under different transmission categories

“…First, the slowing of the decline in all-cause mortality among MSM, MSW, WSM in our study population may be partly explained by the persistently high prevalence of late HIV presentation among those with sexually transmitted HIV in Taiwan over the past 2 decades 34 , 35 . This high prevalence, which contributes to AIDS-related deaths 30 , 36 , may partially nullify the benefits conferred by the reduction of mortality from improved medical care, the implementation of universal ART, and the introduction of a single-tablet regimen.…”

Factors Associated With Delayed and Late Initiation of Antiretroviral Therapy Among Patients With HIV in Beijing, China, 2010–2020

“…There are three outcomes used in this study. The first one is "late ART initiation," which was defined as having a CD4 cell count <200 cells/µL or having a clinical AIDS diagnosis at ART initiation (including having current clinical syndromes, opportunistic infections 3 months before ART initiation or at WHO stage III or IV), a definition used in four studies in China [14][15][16][17]. The second one is "delayed ART initiation," which provided an alternate measure of timely ART initiation based on self-reported HIV diagnosis date, and is defined as having a period of more than 1 month between HIV diagnosis date and ART initiation, a definition used in two national studies in China [5,18].…”

“…Previous studies have rarely compared different outcomes. In China, gender, transmission routes, age, and year of ART initiation were associated with late ART initiation [14][15][16], and marital status was found to be associated with delayed ART initiation [5]. Before 2016, the situation of ART initiation in China has been improving despite the challenges of inactive ART initiation remained [5].…”

Factors associated with late initiation of antiretroviral therapy in Iran’s HIV/AIDS surveillance data

“…In contrast, several studies reported no change or an increasing trend in late-initiating patients, reflecting challenges in implementing the ‘‘treat-all’’ scheme. Lee et al 41 noted a significant decrease in late ART initiation from 77.14% in 2009 to 39.1% in 2019, with a slight increase from 2015 to 2019 (33.03% to 37.80%). In Brazil, Pacheco et al 12 observed an increase from 2014 to 2018 despite a decreasing trend in previous years.…”